Substance abuse treatment as part of a total system of community response

Harold D. Holder Research report Substance abuse treatment as part of a total system of community response Introduction Existing approaches to substance use and abuse in most countries have generated a complex but not always complimentary set of separate programs and approaches in communities, normally labeled as treatment or prevention. Treatment of substance abuse is often separated from other social and health responses to alcohol and other drug harms. Current government programs can exist like silos or separate closed systems such that even within the recovery/treatment organizations there are many alternative approaches, programs, and policies which often compete for government funding and public support. This observation is based on a number of reviews of treatment systems. See Rist et al. (2005) for a review of new developments in alcoholism treatment patterns in Europe which illustrates Acknowledgment Presented at Models, implications and meanings of alcohol and drug treatment systems (a thematic meeting of the Kettil Bruun Society for Social and Epidemiological Research on Alcohol) Stockholm, Sweden on 7 9 October 2009. Submitted 29.04.2010 Initial review completed 20.05.2010 Final version accepted 09.11.2010 A B S T R A C T H. Holder: Substance abuse treatment as part of a total system of community response Treatment of substance abuse in many communities throughout the world is often separated from other social and health responses to alcohol and other drug harms. Current responses exist like silos within the community. In addition, there are population-level policy approaches concerning the distribution and sales of alcohol and the restrictions on and enforcement of illegal drugs which also exist only loosely connected to treatment (or prevention for that matter). A systems approach to substance abuse and related problems is described in which evaluation addresses both clinical patient needs as well as overall performance demonstration. Effectiveness can be measured both by population level reductions in use and associated problems, a second level of accountability, i.e., documented reductions in problems of at risk groups or clients whose drinking or drug use patterns place them at risk for future problems, and a third level of response for individuals with clearly identified substance-related problems, which requires intervention at the person level (typically called treatment). Thus within such a comprehensive system, treatment and prevention would lose their separate identities and would be employed according to local needs and NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 27. 2010. 6 549

the potential to achieve desired effects where the overall system is required to select the mix of strategies which maximizes effectiveness at each level. Key words substance abuse treatment system, prevention, evolution model, population -level effects some of these points. Currently in most countries, there are many agencies, ministries, and organizations providing services and programs related to substance abuse. The cross-national review of alcoholism and drug abuse treatment services in Europe and other countries by Klingemann et al. (1992) and Klingemann and Hunt (1998) as well as organizational analyses completed by Durkin (2002) find that substance abuse programs are not typically organized to provide either systematic clinical evaluation nor performance evaluation overall. Further Warner (2008) finds that very few of existing substance abuse treatment services are providing overall health screening and thus are not evaluating their programs in terms of effects on either total population or at risk sub-populations. Similarly local prevention efforts operate separately from one another, compete for funding among themselves as well as exist largely independent of treatment with the same community. For example, simply having law enforcement (or the judicial system) identify and mandate treatment services for convicted persons is not the same as operating and evaluating treatment within a total system. As Holder et al. (2005) have documented, prevention programs for substance abuse may be co-located within the same organization for treatment. Due to this diversity prevention efforts may not typically operate as though part of a common system. In addition, there are population-level policy approaches concerning the distribution and sales of alcohol and the restrictions on and enforcement of illegal drugs which also exist only loosely connected to treatment (or prevention programs for that matter). This is especially in the Nordic countries, specifically Finland, Norway, Sweden, and Iceland, which have a long tradition of using public policy as a means to reduce substance abuse harm. See reviews of these policies and their history in Holder et al. (1998) and Trolldal et al. (2000). Over time approaches to substance abuse have been either person-specific interventions in reducing substance abuse by individuals (this is typically the domain of treatment) and purposeful efforts to reduce subgroup or population-level substance abuse and/or associated problems by education or environmental/policy interventions (typically the domain of prevention). There is clear evidence of harm 550 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 27. 2010. 6

reduction strategies for substance abuse (Ritter & Cameron 2006) which may or may not be utilized in practice. Wells et al. (2006) provide insights as to why substance abuse treatment programs do not operate or link with prevention efforts (even with demonstrated effectiveness). These authors find the lack of funding incentives for actually operating prevention initiatives and the lack of accountability for overall effects on substance abuse problems as key factors. This is echoed by Merrill et al. (2006) which when looking at a large national school-based prevention effort find that the program is not organized to select evidence-based strategies nor to document overall effectiveness as a part of policy requirements. Further see discussions in Lisansky-Gomberg (2003), Brienza and Stein (2002), Tonigan (2003), and Babor et al. (2010) concerning treatment services and prevention approaches as well as Holder (1998a) concerning treatment cost-effectiveness. Over the past 25 to 30 years, a substantial body of scientific data and literature on the epidemiological, etiology, treatment and prevention of substance abuse has accumulated. From these data a better understanding of the factors that either enhance or diminish the incidence, prevalence, and consequences of substance problems has emerged. What is missing is not scientific information on which to base effective treatment and prevention responses to substance abuse. What is missing is an approach to stimulate evaluation of effects of specific interventions or overall effectiveness or a group of interventions in terms of population level effects. In most instances, there is little or no consistent documentation of effectiveness nor requirement that such services and programs or policies be modified to take advantage of best scientific evidence of potential impact. For example, Fuller et al. (2007) in a review of existing substance abuse treatment programs find a significant gap between evidencebased practice (EBP) innovations and their adoption. Further they identify 6 elements which are critical to the adoption and maintenance of evidence-based practices in their programs including program evaluation for individual care as well as overall documentation of performance which can be used as feedback to staff to improve overall performance. As discussed in Babor et al. (2010), the provision of treatment is part of a comprehensive approach to alcohol-related problems and in terms of the reduction of human suffering, and treatment can be considered as a form of prevention. Further, Babor et al. (2010) concludes that when provided in response to early risky drinking to reduce further alcohol problems, it is called secondary prevention and when implemented to reduce the further damage of heavy, dependent drinking, when it is initiated to control the damage associated with chronic drinking, it is called tertiary prevention. Anderson and Baumberg (2006) have concluded that while prevention policies have been proven to be effective in lowering alcohol problems and harm at the population level, there is limited evidence of the efficacy of individual interventions reducing population-level alcohol problems alone. Both Anderson and Baumberg (2006) and Babor et al. (2010) propose a mix of treatment, prevention and policy interventions in a comprehensive approach to reducing harm. This is also reflected by Humphreys et al. (1997) NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 27. 2010. 6 551

who discuss the limitations of current evaluation approaches in governmentsponsored substance abuse treatment and describe approaches to evaluation which can both support clinical needs (effects for individual patients) and which can be relevant to public policy (see also Moos & Finney 1983; McClellan et al. 2000). The goal of this paper is to present a systems approach to substance abuse treatment and prevention in which the documented reduction of abuse and related harms both at the individual patient level as well as overall effectiveness are essential in system design. A systems approach to evaluation is about establishing a means to evaluate both individual and population-level effects, and integrating evaluation as a part of natural operations. Complex systems are designed to achieve specific outcomes. Three essential levels of evaluation for this system are proposed. Also one example of such an actual system which uses all three levels as described and currently exists (in one form or another) in every developed country. Further key steps to develop such a systems approach are given as well as illustrations of logic models for drinking and driving and methamphetamine treatment and prevention which provide alternative examples. Thus this paper describes how evaluation of outcomes can be inherent such that the system seeks to improve over time, i.e., adaptation based upon success or failure. (See Costello 1975) A systems approach for reducing substance use and abuse A systems approach to reducing substance use and abuse problems is proposed to be an organizing frame work with the requirement to utilize existing scientific evidence to identify practices and interventions most likely to make the system effective and to make evaluation a natural part. This is not a description of ideals or even a replacement of current treatment and prevention approaches in practice. Rather this approach identifies key functions which can support both an evaluation of effectiveness and enable the system to improve over time and which could be applied to existing programs and interventions. For example, a systems approach to public education can identify the essential functions necessary to effective education including necessary funding to support activities, alternative educational delivery structures, measurement of student learning and improvement, and overall management processes. However, the specific shape and location of schools, content of classroom teaching, certification of teachers, and testing of students are to be developed specific to the goals and objectives of the system and the community or culture in which it exists, i.e., seeking alternative operational approaches to achieve system functions. Are there elements of this systems approach to substance abuse already existing? As Lisansky-Gomberg (2003), Brienza and Stein (2002), Tonigan (2003), Babor et al. (2010), Rist et al. (2005), Humphreys et al. (1997) and many others have described many essential ingredients of successful treatment and prevention exist in practice and there have been a number of studies which both assess existing services and suggest appropriate alternatives to improvement as cited above. Thus this paper is not proposing totally new ideas 552 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 2 7. 2 0 1 0. 6

(or ideals) which have not been considered previously. What may be considered as unique in this paper is an emphasis on population-level as well as individuallevel evaluation of effectiveness and an expectation that services, programs, approaches, and policies will be designed and implemented utilizing the best available scientific evidence, and that the specific goals of such a system would be clearly defined and management held accountable. Standards for performance evaluation within a systems approach Evaluation of effectiveness is proposed to occur with three general levels of accountability as illustrated in Figure 1. Thus the first level of accountability is the reduction of specific substance abuse problems for the entire community (this has been described by Holder 1998b; 2001). A second level of accountability would be reductions in problems in subgroups whose members have clearly identified social or health problems or have risk for future substance related problems. In this way, the second level is a type of early intervention component for the system and might include brief intervention delivered via existing general medical or health services (see Wutzke et al. 2001; Babor & Higgens-Biddle 2000) or targeted educational or support programs, e.g., as might be delivered for disadvantaged children, or youth, or families with risk profiles (Lisansky-Gomberg 2003). In practice, interventions at this level (depending upon the population being served) could mix smoking prevention with moderate drinking interventions or diet education to reduce obesity with heavy drinking prevention. Interventions here could also counsel persons whose drinking and/or drug use patterns puts them at risk for future problems. The point here is not to specify specific types of interventions but rather to provide incentives to support system management to seek the most cost effective mix of services for this level, accounting for the characteristics and needs of the population being served. A third level for the system is a remedial response to the identified current problems of individuals who are clearly 1 Universal or Community Wide Approaches 2 3 Strategies which target the entire community Example: Drinking and driving detterence indicated or identified approaches Strategies which target subgroups with risk profiles Example: First DUI Offenders targeted approaches (treatment) Strategies which work with individuals with identified problems Example: Multiple DUI offenders Figure 1. Levels of evaluation in a systems approach to substance abuse NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 27. 2010. 6 553

manifesting substance abuse problems. Thus these clients are engaged in treatment approaches or modalities which have demonstrated effectiveness, i.e., are evidence-based, to reduce individual substance abuse problems. There are many possible treatment and recovery approaches which the system might utilize based on best scientific evidence, depending upon the potential or actual effects realized in reduced problems within the client population. For example, see Raistrick et al. (2006). While these three levels roughly correspond to the public health model of primary, secondary, or tertiary prevention, such a comprehensive system treatment and prevention would be employed according to local needs and the potential to achieve overall desired effects, i.e., reduce population-level substance abuse problems. Thus a type of backup would be created in which the failures of more general or universal strategies (people who fall out, drop out or resist, or have unique individual needs) could be served via more customized strategies. In this case, reducing existing barriers to recovery or increase the demand for recovery services would be essential. For example, if a community had a large number of female drug dependent users for whom existing services were not effective, then a specific service intervention which accounted for gender and social background factors might be necessary. One example of an existing system which utilizes all three performance standards Such a system for reducing substance abuse problems actually exists in an unplanned way, i.e., general strategies backed up by subgroup-specific strategies which are further backed up by individual strategies. This occurs in public safety efforts to reduce drink driving. See Figure 1. At the first level, population level countermeasures for drink and driving are designed to reduce overall incidents of driving after and during drinking. Such countermeasures have been shown to have effects in reducing traffic crashes at the population level, including the use of random breath testing, lower limits for legal blood alcohol concentration (BAC), suspension of driving licenses, and routine enforcement (Babor et al. 2010). Individual drivers do come to the attention of the police as a result of routine surveillance (enforcement) but also as a result of breath testing in conjunction with a traffic crash. Most arrested drinking drivers are first time offenders who have not previously been arrested for drinking and driving or have not had a traffic crash related to drinking. These first time offenders rarely repeat or are rearrested as the original arrest and sanctions are sufficient to reduce future problems, i.e., a general intervention program assessment appears to be sufficient in reducing recidivism in this population of risky drivers. This is an example of a second level system response. A highly significant group within the drink driving population is multiple offenders who are arrested several times, continue to drink and drive, and come to the attention of the police (largely because of their overall exposure to detection and the many driving trips while impaired). Individually they have a much higher risk for traffic crashes. This subgroup clearly requires a specific mix of incarceration 554 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 2 7. 2 0 1 0. 6

and other sanctions and rehabilitation as they are often less affected by more general population strategies to prevent drinking and driving or by the second level of remediation. Thus, this local set of responses to alcohol-involved traffic crashes provides a simple example of the concept of how general universal prevention can be used to affect most of the population at risk (general driving population) backed up by programs/strategies to reduce future risk of alcohol-involved traffic crashes. How could such a comprehensive system be designed? In order to plan and design such a system, the following, suggested steps are proposed: Step 1: Identify alcohol or other drug-related outcomes which are to be achieved: Outcomes for the system can be proximal, intermediate, or distal outcomes (i.e., final outcome of interest). Intervention or longitudinal research determines whether substance abuse and/or associated problems change as a result of altering (either through intended change by planned prevention or unplanned natural/ unintentional change) specific outcomes, either at the individual person level, at the small targeted group level, or at the population level. Outcomes could be identified at many points in a system plan, here outcome primarily refers to distal or final outcome(s) for which the system is accountable. Outcomes should be measured in terms of changes in behaviors or events of interest. For example, changes in attitudes toward serving alcohol to minors are not a substitute for actual changes in behaviors related to not serving minors which is not a substitute for percentage of underage persons who actually drink over the past 30 days. Similarly, the monthly number of alcohol-dependent clients enrolled in services is not the same as percentage of clients who are actually abstinent after 30 or 90 days. Step 2: Identify key intermediate or intervening (causal) variables: These are the variables or factors that have been empirically shown to affect the selected outcome(s) and moderating variables that are known to enhance or diminish the relationship of the intervening variables with outcomes. Three types of scientific research can be identified in supporting a scientifically informed system: Descriptive and observational research illustrates that a particular variable(s) is generally related to the use of a particular substance or associated problem. Associative or relational research examines the association of one or more specific variables with substance abuse and/or associated problems, i.e., this variable appears often with a specific problem or similar problems. Such variables are documented in Holder et al. (2005) along with a summary of scientific empirical evidence. Step 3: Develop a logic model: A logic model is a display of a sequence of steps that describes the conceptual framework used to define and address a problem through implementing programs, practices, or policies. (see Rogers 2005; Weiss 1972). A Logic Model is not an ideal, i.e., this is the only way for a system to be designed. Rather a logic model can be an essential evaluation tool to display the best available scientific evidence about key variables and their relationships necessary to be effective at the client level and NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 27. 2010. 6 555

population level for a specific substance abuse problem. (Conrad & Randolph 1999; Millar et al. 2001; Rossi et al. 2004) While there are many forms of logic models, the logic model recommended here includes a specification of 1) the system goal or goals to be achieved, i.e., specific alcohol and/or drug related behavior or events which is (are) to be reduced or changed (as shown in Step One above), 2) the intermediate (sometimes called causal ) variables which need to be changed (or considered) in order to achieve the system goal, and 3), the intervention components or activities designed to change key or targeted intermediate variable(s). Thus a logic model is expected to specify the causal linkages among key intermediate variables, and between intermediate variables and intervention components that can affect these intermediate variables, and the linkages between all of these and the desired changes in alcohol and drug outcomes. See Birckmayer et al. (2004) for documentation of key variables in substance abuse which are used in the examples below. The relationship of any intermediate variable to the outcome and to other variables should be based upon the research evidence of the relationship of the intermediate variable to the specific substance abuse problem being addressed by the system. In some cases, direct empirical evidence of the relationship of the intermediate variable to another variable may not exist as shown in the causal model. In these situations, the relationship is presented in theoretical terms that is, reasoned argument, based upon other research evidence that can be generalized to the situation (research citations are included). For example, evidence that the drug availability (ease of access of alcohol and tobacco increases use) could provide empirical support that ease of access to illicit drugs is a key variable. See documentation by Holder and Treno (2005). If there is no direct empirical evidence of the intermediate variable to substance abuse problem, the relationship could be presented in theoretical terms that is, reasoned argument, based upon other research evidence from such variables in other conditions that can be generalized to the case or situation. In addition, the relationship of each intermediate variable to any other key intermediate other variable is also shown and the research evidence presented, for example, Low alcohol prices high risk drinking alcohol relation harms Motivational interviewing abstinence reduced medical care Step 4: Select the specific variables which are to be targeted for intervention: This identifies key variables which are (or there is empirical evidence of a potential) to be changed through purposeful intervention. Rarely does a treatment or prevention intervention simply reduce an outcome directly, i.e., a key intermediate variable or a cluster must be affected in order for a community level or individual level problem to be reduced. Because few intermediate variables are easy to change, typically multiple components or activities are needed. However, more important than the number of components or activities is the efficacy or demonstrated potential to be effective of each component or activity. That is, one 556 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 2 7. 2 0 1 0. 6

very effective prevention intervention or activity may be more important than several relatively ineffective activities. Further by directly measuring changes in key variables, it is possible to document (evaluate) whether the strategies being implemented are actually having an effect on targeted variable(s). Step 5: Select the strategies, treatment modalities, policies or programs which the system will undertake: This selection must be based upon the research evidence that has been shown capable of affecting this intermediate variable. In reviewing research articles, one must ask What are some of the elements of credible evidence? Some strategies are stronger than others and a combination of strategies to measure the same variable using different sources adds to the strength of the evidence. For example, self-report on behavior is often the most commonly used measurement strategy, but for sensitive data, such as drug and alcohol abuse, selfreport may not provide very accurate data. Thus, adding another source of data such as archival data on DUI arrests or emergency room visits or collecting data from others such as from a spouse or life partner, a teacher or friend can increase confidence that the data are accurate especially if the data are comparable. Note that most published studies of effectiveness of treatment or prevention under scientifically controlled conditions emphasize internal validity, that is, the degree to which the intervention could cause the changes desired in the outcomes measured. They do not typically address with such systematic rigor the degree to which the results are generalizable to other populations, settings, or circumstances, i.e., external validity. This is where planners and managers must incorporate the evidence into their planning with appropriate caution and judgment about relevance to the local situation and be prepared to modify the design based upon real world experience. See discussion of treatment evaluation challenges by Moos and Finney (1983). Step 6: Design of overall system utilizing the logic model: Creating interventions at all three levels for the system requires identifying possible interventions and then selecting the particular intervention components or activities that have sufficient strength to improve each or key selected intermediate variable(s) at the individual, small group, or community level. Which interventions (policies, programs, or program activities) have the greatest demonstrated impact upon each of the selected intermediate variables? Is there sufficient evidence that these interventions (policies, programs, or program activities) are sufficiently powerful that they will actually markedly change each selected intermediate variable and what is the evidence for this conclusion? There are situations when no studies are available that evaluate a specific intervention, or effects of an intervention on the targeted substance or population, i.e., no direct scientific evidence of effects. In this situation, system planners may still desire a specific intervention as part of a comprehensive approach to system programming. What are some reasonable arguments that can be made for such a selection? Such elements as these are important to include: The proposed intervention is based upon a similar theory, content and structure to other interventions that have empirical evidence of effectiveness. For NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 27. 2010. 6 557

example, evidence of limiting access to tobacco products as a means to reduce youth smoking could be used to support a strategy to limit youth access to drugs, even though there is little evidence of specific effects from controlled research on a specific illegal drug which may be targeted. The proposed intervention has been used by a community through multiple iterations and data have been collected indicating it is effective, though not using a specific controlled research design. The intervention is based on published principles of prevention and treatment and discussion of the intervention description clearly incorporates these principles It is essential that local knowledge of culture, context, and politics be considered as a part of the system planning process. The advice of local practitioners who know the community, population segments, and local history of experience with such interventions are critical in order to combine and adapt the proposed interventions into a coordinated system. Thus, what is the feasibility of proposed system policies, programs and practices, i.e., are they culturally feasible, given the values and social and cultural context of the community, are they politically feasible given the existing power structure, are they administratively feasible, given the existing structure of relevant organizations, are they technically feasible, given the staff capabilities and program resources, and are they financially feasible, given reasonable estimates of costs and likely fiscal resources? For these reasons, consultation with local practitioners and residents in the process of translating the research to their culture and context is an essential part of good systems planning. The empirically confirmed relationships of intermediate variables to the distal outcome support the use of specific interventions. For example, Responsible Beverage Service (RBS) as an intervention to reduce overserving of alcohol at bars, restaurants, or pubs has been demonstrated to decrease service to intoxicated patrons and underage persons, reduce the number of intoxicated patrons leaving bars, and decrease the number of car crashes (See empirical evidence of such effects in Babor et al. 2010; Treno 2003). In addition, in keeping with a comprehensive systems approach to reducing such outcomes, the logic mod- Examples of logic models We have few examples in practice of this proposed system approach to substance abuse treatment and prevention. However, it is possible to propose, for illustration only of the concepts of this paper, some examples of logic models. There are many possible models which could be explored or proposed. Thus these examples are not given as ideals but as simple illustrations. Figure 2 shows an example of logic model for reducing alcohol-involved motor vehicle crashes related to the key intermediate variables as specified. Based upon the empirical research, the key intermediate variables which impact drinking driving and related harm are shown. See Babor et al. (2010), Voas et al. (2008), and Horwood and Fergusson (2000) for empirical background for selection of key variables in this model as well as Birckmayer et al. (2004). 558 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 2 7. 2 0 1 0. 6

Retail & economic availability (outlet density, hours, days of sale discount pricing and taxes) Alcohol sales & service enforcement & sanctions Alcohol serving and sales practices First offencer drink driving interventions DUI enforcement Multiple offender drink driving treatmen programs Drinking Perceived risk of DUI arrest Driving after drinking Alcohol-related motor vehicle crashes Community norms drinking Drinking context (atmosphere designed to minimize contrlos on behavior) Individual, family and peer factors Alcohol promotion (adversiting, sponsorship of commuity events) Comprehensive system for reduction of alcohol-involved motor vehicle crashes Figure 2. Logic model for a comprehensive system to reduce alcohol-involved motor vehicle crashes. el provides for an intervention with first drink driving offenders (person arrested for drink driving for the first time) in order to reduce future drink driving events by this subgroup as well as a set of strategies to address the specific population of persons who are arrested for multiple drink driving offenses. Figure 3 illustrates a simple alternative logic model for illicit drug use, e.g., a systems response to methamphetamine including interdiction to reduce supply and availability and a recovery (detoxification and treatment) response to individual dependency. In this example, the logic model is derived from the empirical evidence of similar intermediate variables from other drugs, other than methamphetamine as the research evidence concerning key variables in this logic model is limited and there are few published studies on these variables specifically addressing methamphetamine. See Birckmayer et al. (2008) for documentation including empirical and theoretical rationale for this logic model. Also see documentation of key variables for this logic model in Johnson et al. (2007) and Miller et al. (2009). Summary and conclusions The systems approach proposed here is to identify elements or functions within an actual system in which evaluation of treatment and prevention efforts can occur. Further, these functions can be used to stimulate accountability for reducing substance abuse problems and harm and to support the increased use of evidencebased practices and policies. The effectiveness of this system is to be measured both by population level reductions in use and associated alcohol and drug problems, NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 27. 2010. 6 559

Enforcement Community norms (enforcement & use) Meth beliefs attitudes perceived social norms expectancies Community concern about meth harm Laws (production supplies, sale, & possesion) Perceived risk of arrest (production, sale or possession) Meth production Price Supply available for purchase Meth use Detox and treatment for meth dependency Meth associated problems Figure 3. Metamphetamine logic model a second level of accountability or evaluation, i.e., documented reductions in the problems of subgroups who have risk profiles, and recovery or relapse of individual clients with clearly identified individual drinking and/or drug use problems. The proposed design is such that the system evolves and adapts as it builds cumulative evidence of what works and why it works and which kinds of interventions have the greatest impact. As research provides more information about what kinds of strategies affect specific intermediate variables, the logic models can utilize increasingly effective actions. In this paper, a system is not necessarily a single organizational entity but rather an integrated and interacting set of interventions, programs and policies which work together over time to achieve specific goals. Thus within a single or across multiple organizations, there may be several functioning systems, each with its own unique collection of elements and performance standards as illustrated in the examples above. Some of the elements may be shared in common and many may be unique. Thus what makes a system is the intentional design to address specific goals and to integrate all necessary elements for goal achievement. The trust of this paper is to extend beyond organizational boundaries and to seek ways to integrate across system elements. Perhaps the response to drink driving is a good example of a quasi-functioning system (though it could certainly be improved) which exists across several organizations in most communities or countries. For such a comprehensive, self-adapting system to be created in practice would not require existing treatment and prevention organizations and agencies to be abandoned. Rather the key functions presented in this paper, if put into practice, would stimulate improved evaluation of effectiveness at the individual, risk group, and population levels. If evaluation of effectiveness becomes an essential function, then low or non effective approaches 560 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 2 7. 2 0 1 0. 6

would need to be replaced with evidencebased approaches which increase effectiveness. Why has existing organizations or agencies which provide treatment and evaluation, not incorporated these functions? Some of the complex answers to this question are addressed in the introduction to this paper which reviews a number of assessments of contemporary treatment and prevention and the role of evaluation. Perhaps, in a simplistic answer, governments do not require treatment or prevention efforts to be evaluated in practice and thus there is limited accountability. Further, in a time of considerable unstable economic conditions, the cost and resources to support evaluation are simply not provided. As a result, without both accountability and support of routine evaluation, the viability of the proposed systems approach is limited. However, this does not mean that establishing operating systems, in which evaluation of effects can not be created or is technically infeasible. Perhaps the greatest limiting factor is the will of government ministries and municipal agencies to actually require this level of evaluation and accountability of substance abuse treatment and prevention in practice. Harold D. Holder, researcher Prevention Research Center Pacific Institute for Research and Evaluation Berkeley, California, USA E-mail: holder@prev.org REFERENCES Anderson, P. & Baumberg, B. (2006): Alcohol in Europe: a public health perspective. London: Institute of Alcohol Studies Babor, T.F. & Higgins-Biddle, J.C. (2000): Alcohol Screening and Brief Intervention: Dissemination Strategies for Medical Practice and Public Health. Addiction 95 (5): 677 686 Babor, T.& Caetano, R. & Casswell, S. & Edwards, G. & Giesbrecht, N. & Graham, K. & Grube, J. & Hill, L. & Holder, H. & Homel, R. & Livingston, M. & Österberg, E. & Rehm, J. & Room, R. & Rossow, I. (2010): Alcohol: No Ordinary Commodity: Research and Public Policy. Second Edition, Substantially Revised. New York: Oxford University Press Brienza, R. S. & Stein, M. D. (2002): Alcohol use disorders in primary care: Do genderspecific differences exist? Journal of General Internal Medicine 17 (5): 387 397 Birckmayer, J. & Fisher, D.A. & Holder, H.D. & Yacoubian, G. S. (2008): Prevention of Methamphetamine Abuse: Can Existing Evidence Inform Community Prevention? Journal of Drug Education 38 (2): 165 183 Birckmayer, J. & Holder, H.D. & Yacoubian, G. S. & Friend, K. B. (2004): A General Causal Model to Guide Alcohol, Tobacco, and Illicit Drug Prevention: Assessing the Research Evidence. Journal of Drug Education 34 (2): 121 153 Conrad, K. J. & Randolph, F. L. (1999): Creating and using logic models: Four perspectives. Alcoholism Treatment Quarterly 17 (1 2): 17 32 Costello, R. M. (1975): Alcoholism Treatment and Evaluation: In Search of Methods. Substance Use and Misuse 10 (2): 251 275 Durkin, E.M. (2002): An Organizational Analysis of Psychosocial and Medical Services in Outpatient Drug Abuse Treatment Pro- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L. 27. 2010. 6 561

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